Application for Annuity Annuity Plus Foresters Retirement Income Funds Plus

foresters.com 105223 CAN (01/12) Application for Annuity Annuity Plus Foresters Retirement Income Funds Plus

foresters.com Application for Annuity For purposes of all pages of this document the following words and phrases are defined. The word application means this application for Annuity. The acronym FR means the Foresters Financial Representative who signed this application. The words we, our and us mean The Independent Order of Foresters ("Foresters"). The words you, your and Proposed Annuitant(s) mean the person(s) proposed as an annuitant in this application. The acronym FRIF Plus stands for Foresters Retirement Income Funds Plus. The term GIA refers to Guaranteed Interest Account, with the number following the term GIA representing the length (in years) of the account. General Information Information about the Proposed Annuitant Please note order of birth date is (mmm/dd/yyyy). Name (first, middle, last) Social insurance number Birth date (mmm/dd/yyyy) Male Female All phone numbers must include area code. Marital status Home address (use mailing address) Home phone number City, province Postal code Are you a member of Foresters? Yes. Indicate certificate number(s). No. Applying for membership. Original document shown to verify identity. Driver s license number and province Passeport Other government I.D. Beneficiary Information Document number Name and address of each primary beneficiary of the Proposed Annuitant Relationship % Share Total must equal 100%. Rights of a contingent beneficiary only arise if no primary beneficiary is living when the annuitant dies. Name and address of each contingent beneficiary of the Proposed Annuitant Page 2 of 7 Relationship Foresters is the trade name and a trademark of The Independent Order of Foresters and its subsidiaries are licensed to use this mark. % Share Total must equal 100%.

Annuity Plus Complete this page only if applying for an Annuity Plus certificate This annuity is being applied for as: Registered Annuity Plus Locked-in Not locked-in You have requested Foresters apply to register the certificate as a Retirement Savings Plan under the Income Tax Act (Canada) and any applicable provincial Income Tax Act. Non-registered Annuity Plus Amount being paid to Foresters by cheque along with this application $ Completed PAC Card and void cheque required if PAC selected Completed only if contributor is not the Proposed Annuitant Amount being transferred under the Income Tax Act (Canada) by the Company(ies) indicated on the transfer form(s) $ (estimated amount) Establish Pre-Authorized Chequing (PAC) amount $ Establish Billings amount $ Billing or Pre-Authorized Chequing frequency Monthly (PAC only) Quarterly Semi Annual Annual No Billing/PAC Contributor (if other than Proposed Annuitant) Name (first, middle, last) Social insurance number Contributor is Spouse or common-law partner or Other (non-registered only) Relationship to Proposed Annuitant (if Other) Original document shown to verify identity. Driver s license number and province Passeport Other government I.D. Document number Initial Lump Sum refers to amounts transferred initially via transfer forms or cheques at the time of application Accounts Allocation of Premium Initial Lump Sum Percentage Daily Interest Account % GIA-1 Year % GIA-2 Years % GIA-3 Years % GIA-4 Years % GIA-5 Years % GIA-10 Years % (Total must equal 100%) (Whole numbers only) Page 3 of 7

Foresters Retirement Income Funds Plus Complete this page only if applying for a Foresters Retirement Income Funds Plus certificate. Select only one mode Select only one method Attach void cheque if Direct Deposit selected Select only one schedule Minimum Income Payments may be in excess of requested level payment Select either Yes or No I request Foresters apply to register the certificate as a Retirement Income Fund under the Income Tax Act (Canada) and any applicable provincial Income Tax Act. Amount being transferred under the Income Tax Act (Canada) by the Company(ies) indicated on the transfer form(s) $ (estimated amount) Mode of Income Payments Monthly (Direct Deposit only) Semi-Annual (Direct Deposit or cheque) Quarterly (Direct Deposit or cheque) Annual (Direct Deposit or cheque) Method of Income Payments Direct Deposit (void cheque required, all modes) Cheque (Quarterly, Semi-Annual, Annual) Schedule of Income Payments (Amount requested must meet current administrative rules) Minimum Level Payment of $ prior to tax withholding Level Payment of $ after tax withholding Minimum Income Payments Is the Minimum Income Payment based on your spouse or common-law partner s age? No Yes (if Yes, please provide the following spouse or common-law partner information) Spouse or Common-Law Partner Information Name (first, middle, last) Birth date (mmm/dd/yyyy) No later than December of the year after issue Premium Allocation is for payments made to Foresters Income Payment Allocation is for payments made by Foresters to you Original document shown to verify identity and date of birth. Driver s license number and province Passeport Other government I.D. Document number Income Payment Start Date I wish for my income payments to start in / (mmm/aaaa) Premium Allocation (premiums paid to Foresters) Investment Accounts Percentage Daily Interest Account 129 % GIA-1 Year 131 % GIA-2 Years 132 % GIA-3 Years 133 % GIA-4 Years 134 % GIA-5 Years 135 % GIA-10 Years 130 % Canadian Money Market Fund 054 % Canadian Balanced Fund 053 % Canadian Bond Fund 051 % Canadian Equity Fund 052 % Canadian Index Fund 062 % American Index Fund 061 % Eurasia Index Fund 063 % Global Index Fund 064 % (Total must equal 100%) (Whole numbers only) Page 4 of 7 Income Payment Allocation (payment made by Foresters to you) Investment Accounts Percentage Daily Interest Account 129 % GIA-1 Year 131 % GIA-2 Years 132 % GIA-3 Years 133 % GIA-4 Years 134 % GIA-5 Years 135 % GIA-10 Years 130 % Canadian Money Market Fund 054 % Canadian Balanced Fund 053 % Canadian Bond Fund 051 % Canadian Equity Fund 052 % Canadian Index Fund 062 % American Index Fund 061 % Eurasia Index Fund 063 % Global Index Fund 064 % (Total must equal 100%) (Whole numbers only)

Other Annuity or Insurance Contracts Do you have another annuity application pending with Foresters or any other insurer?.... Yes No Will a Proposed Annuitant stop paying premiums, reduce the face amount of coverage or otherwise discontinue existing life insurance coverage or an annuity if the annuity applied for in the application is issued?... Yesi No (If Yes, complete Foresters replacement / rollover / disclosure & comparison statements. Include existing life insurance or annuities in the process of being lapsed or surrendered, and those completed within the past 13 months.) Agreements applicable to Proposed Annuitant(s) I/we means the Proposed Annuitant, owner (if applicable), Proposed Annuitant s spouse or common-law partner (if applying for an Annuity Plus and the Annuity Plus is to be a spousal or common-law partner contributor plan, or if applying for a FRIF Plus and the Minimum Income Payment is to be based on the age of the spouse or common-law partner of the Proposed Annuitant), and parent (if juvenile coverage is applied for), signing below. I, as evidenced by my signature below, have read, understood, agree, and declare: 1. I have read this application and confirm that every question was asked and the answers contained herein are complete and true to the best of my knowledge and belief. All statements made in this application shall be representations and not warranties. 2. No person, including a FR, has the authority to waive the disclosure of full, complete and truthful information in response to each question in this application. Such person also has no authority to write down an answer given to a question in the application other than the answer that was provided to the FR. 3. The certificate will not take effect until both (a) and (b) immediately below are met. (a) The certificate has been delivered to the Proposed Annuitant, or owner. (b) Initial premium(s) is/are paid during the lifetime of the Proposed Annuitant(s). A cheque provided to Foresters is not paid to Foresters unless and until the cheque is honored for payment by the banking institution of the account from which the payment is to be drawn. 4. I understand the potential consequences of deliberately providing false information in this application. 5. Any cheques must be payable to Foresters. 6. Products offered under the Annuity Plus section of this application are comprised of Daily Interest Account, and Guaranteed Interest Accounts. The surrender of the certificate and each withdrawal, or transfer of money, is subject to market value adjustments. 7. Investment Options offered under the FRIF Plus section of this application are comprised of a Daily Interest Account, Guaranteed Interest Accounts of various terms, and Segregated Funds. The surrender of a FRIF Plus certificate will be subject to surrender charges, and market value adjustment. Each withdrawal from a FRIF Plus certificate is subject to surrender charges, market value adjustments and an administration fee. The transfer of money between investment options is subject to market value adjustment and an administration fee. 8. I have received and read the document entitled Privacy Notice which describes the policy and practices of The Independent Order of Foresters and its wholly owned subsidiaries with respect to their collection, use, disclosure and retention of personal information. The parties hereto state their express wish that this Agreement as well as all documentation contemplated hereby or pertaining hereto or to be executed in connection herewith be drawn up in English French Special Instructions. Signed at: City, province Date (mmm/dd/yyyy) Signature of Proposed Annuitant Owner and parent signature only required if Annuity Plus Signature of owner (if not Proposed Annuitant) Signature of parent (if Proposed Annuitant is juvenile) Signature of Proposed Annuitant s spouse or common-law partner (if applicable) Date (mmm/dd/yyyy) Signature of the Proposed Annuitant s spouse or common-law partner only needed if applying for an Annuity Plus and the Annuity Plus is to be a spousal or common-law partner contributor plan, or if applying for a FRIF Plus and the Minimum Income Payment is to be based on the age of the spouse or common-law partner of the Proposed Annuitant. Page 5 of 7

FR Certification I certify that: I asked all questions as written in the application. I have recorded all answers as given to me by the Proposed Annuitant(s). I have not made or agreed to make a rebate of the premium for this annuity. I recommend acceptance of this application except as qualified in Special Instructions. I have made no misrepresentation(s) about the Foresters product(s) applied for in this application. I have made no promise(s) regarding the benefit(s) or future performance of the product applied for, other than as specifically written in the specific product applied for in this application. I have complied with all regulatory requirements applicable to this application. I personally witnessed the signature(s) of the person(s) whose signature(s) appear in this application. I personally reviewed the original photo identification of the person(s) who signed this application. Will the Annuity Plus or FRIF Plus certificate applied for in this application, to the best of your knowledge, replace any existing life insurance contract or annuity contract held by the Proposed Annuitant/Owner?... Yes No (if Yes, please ensure details are noted in Special Instructions or below, in the Details/Notes section) Full printed name of FR FR Signature Date (mmm/dd/yyyy) Details/Notes FR # Branch # Office # For Internal Use Only Certificate # Page 6 of 7

Payment Information and Pre-Authorized Chequing (PAC) Authorization First premium payment to be made by cheque (payable to Foresters) Monthly PAC Withdrawals are: Personal related Business related Withdrawal date requested (Check one): 1st 8th 15th 22nd PAC banking information to be taken from: VOID cheque - must be attached Banking Information completed below (Use only if no cheque available) Type of account: Chequing Savings Name of Attach financial institution Void Cheque Street address City Province Postal Code Transit # Bank # Account # PAC Authorization The payor signing below verifies that the payor is an account holder of the account identified on the attached VOID cheque or in the banking information section above and agrees that: 1. Foresters is authorized to draft deductions under the PAC plan from that account or another account later identified or substituted by the payor, for premium and charges for the insurance contract(s) issued in response to the application for the insurance contract(s) to which this PAC Authorization relates; 2. The financial institution from which payments are to be drafted is authorized to treat each draft by Foresters as though the payor made it personally; 3. Foresters reserves the right to determine when the first deduction, if any, will be made and the amount of that deduction for the product issued, however, it will be after the issue date(s) of the applicable insurance contract(s) issued, if any; 4. The PAC plan is effective immediately and will continue until terminated, which either the payor or Foresters may do by providing written notice of 30 days to the other. Payor may obtain a sample cancellation form or further information on the right to cancel a PAC Agreement at his/her financial institution or by visiting www.cdnpay.ca; 5. Should funds not be available due to insufficient funds, the payor authorizes Foresters to draft my account on the next available withdrawal date for those insufficient funds while the applicable insurance contract is in effect; and 6. I understand I have certain recourse rights if any debit does not comply with this Agreement. For example, I have the right to receive reimbursement for any debit that is not authorized or is not consistent with the PAC Agreement. To obtain more information on your recourse rights, contact your financial institution or by visiting www.cdnpay.ca. The Payor waives the right to receive pre-notification of the amount and date of the first debit and of a change in a debit amount required as premium for the insurance contract(s) in effect or a change requested by the Payor by any means. The payor account holder must sign this agreement as his/her name appears on bank records for the account provided. X Name of Account Holder Signature of Account Holder Date (mmm/dd/yyyy) The payor may contact Foresters at the address and phone numbers shown below: The Independent Order of Foresters, 789 Don Mills Road, Toronto, ON M3C 1T9, Canada T 800 828 1540 T 416 429 3000 F 416 429 3896 Foresters is the trade name and a trademark of The Independent Order of Foresters and its subsidiaries are licensed to use this mark. Page 7 of 7 105221 CAN (01/12)